I certify that I have provided an accurate and complete medical and dental history and have not omitted any information. I have had the opportunity to ask questions and have received answers regarding any concerns. I authorize the North Hill Dental team to perform and provide treatment as required. I also understand that the premises are under CCTV monitoring and I consent to this. I authorize the team to contact my physician regarding any relevant medical conditions.
By submitting this form, you confirm that you have read and understood the Terms and Conditions, Privacy Policy, and Terms of Use of North Hill Dental Center prior to submission, and you agree to them. You can review these documents here:
Terms and Policies.
I consent to the collection, use, and disclosure of this personal information for myself, or as the guardian of the patient in this form and accept all policies mentioned above.
